MEASURE #9: MIGRAINE OR CERVICOGENIC HEADACHE RELATED DISABILITY FUNCTIONAL STATUS Headache Quality Improvement Only Measure Description Percentage of patients age 6 years old and older who have a diagnosis of migraine headache or cervicogenic headache and for whom the number of headache-related disability days during the past 3 months is documented in the medical record. This is a system level measure that is to be used for quality improvement purposes only at this time. Measure Components Numerator Statement Number of days during the past 3 months, as categorized* by patients or their caregivers, that they are unable to perform common daily activities (e.g., school, work, household chores, social activities, Independent Activities of Daily Living (IADLS), etc.) due to migraine headache or cervicogenic headache. *Within the past 3 months range of days of disability due to migraine or cervicogenic headache: 0 to 5 days: Little or no disability 6 to 10 days: Mild disability 11 to 20 days: Moderate disability 21+ days: Severe disability Statement Exceptions Supporting Guideline & Other References Survey tool examples: Migraine Disability Assessment (MIDAS) (proprietary tool); Disability in Strategies for Care (DISC); Patient Specific Function Scale (cervicogenic headache). All patients age 6 years old and older who have a diagnosis of migraine headache or cervicogenic headache. Exceptions: Medication exception for not administering a disability tool (i.e., patient has a cognitive or neuropsychiatric impairment that impairs his/her ability to complete the survey). Patient exception for not administering a disability tool (i.e., patient has the inability to read and/or write in order to complete the questionnaire). System exception for not administering a disability tool (i.e., patient does not have insurance to cover the cost of the quality of life assessment). The following clinical recommendation statements are quoted verbatim from the referenced clinical guidelines or evidence papers and represent the evidence base for the measure: This is a system level outcome measure. There are no specific guideline recommendations available that could be cited for this measure. However, this was a strong consensus by the Work Group that headache-related disability needs to be monitored as a patient reported outcome measure (PROM) because of the peer reviewed studies showing the significant association of headache disability, including days lost to work, school, social activities and the effect of headache on IADLs. Rationale for the Measure 2014. American Academy of Neurology. All Rights Reserved. 64
The goal of this measure is to understand headache related disability (risk adjusted/risk stratified) on the system level to indicate where improvements in the management and treatment of patients with headache should be made. Gap in Care On the World Health Organization's ranking of causes of disability, this would bring headache disorders into the ten most disabling conditions for the two genders, and into the five most disabling for women. 1 90% of people with headache have some headache-related disability, and approximately half are severely disabled or require bed rest. 2 Disability: o 9 out of 10 people with headache report they can t function normally during days in which a migraine headache strikes and 3 in 10 require bed rest. 3 o More than 25% of migraine sufferers missed at least one day of work over the past three months due to a migraine. 3 o Nearly 50% of sufferers report their migraines prevented them from doing household chores. 3 o Approximately 30% of people with headache did not participate in a family or social activity due to a migraine. 3 In another study, the eligible sample included 6,329 persons with episodic migraine (EM) and 374 persons with chronic migraine (CM). Men with CM aged 45 to 54 years cost employers nearly $200 per week more than do their EM counterparts. Likewise, for women costs were higher for CM; with the cost differential between EM and CM being $90 per week. After comprehensive adjustment, increases in lost productive time with age were significantly higher in CM than in EM (rate ratio 1.03; 95% confidence interval 1.01-1.05). When age was recoded to a decade, metric rates of lost productive time increased 25% more per decade for CM than for EM (rate ratio 1.25; 95% confidence interval 1.004-1.5). Lost productive time is more costly and increases more rapidly for those with CM than for those with EM as age increases. 4 Opportunity for Improvement Clinicians are advised to base their treatment choice on degree of disability along with attack frequency and duration, non-headache symptoms, patient preference, and prior history of treatment response using a stratified approach to care. In stratified care, initial treatment is individualized based on an assessment of the patients medical needs. One approach to stratification uses the MIDAS to stratify patients into groups with different treatment needs based on the degree of headache-related disability. Stratified care was developed as an alternative to step-care approaches, which begin patients on nonspecific medication with gradual escalation until they obtain effective relief. Results from the DISC study indicate that stratified care provides superior outcomes compared to step-care and that the approach is cost-effective, supporting the US Headache Consortium Guidelines. Stratified care may become the approach of choice for managing migraine in clinical practice. This approach increases the chances of providing appropriate therapy at the patient s initial consultation, sparing the patient a series of failed therapeutic efforts. MIDAS provides a practical tool for helping to implement the recommendations of the US Headache Consortium Guidelines. 5 1World Health Organization. Headache Disorders Fact Sheet. http://www.who.int/mediacentre/factsheets/fs277/en/ Accessed. 8.22.2013 2International Association for the Study of Pain. Epidemiology of Headache Fact Sheet 2012. /www.iasp-pain.org/ Accessed 8.22.2013 2014. American Academy of Neurology. All Rights Reserved. 65
3National Headache Foundation Impact of Migraine: Evaluation Patient Disability http://www.headaches.org/pdf/monograph12.pdf Accessed. 8.20.2013 4Serrano D, Manack AN, Reed ML, et al. Cost and predictors of lost productive time in chronic migraine and episodic migraine: results of the American Migraine Prevalence and Prevention (AMPP) Study. Value Health 2013; 16 (1): 31-38. 5 Lipton RB, Silberstein SD, The role of headache-related disability in migraine management. Implications for headache treatment guidelines. Neurology 2001 56 (1): S35-S42 Measure Designation Measure purpose Type of measure Level of Measurement Care setting Data source Quality improvement Only Outcome System Level Measure Outpatient visits Electronic health record (EHR) data Administrative Data/Claims (inpatient or outpatient claims) Administrative Data/Claims Expanded (multiple-source) Paper medical record Technical Specifications: Administrative/Claims Data Administrative claims data collection requires users to identify the eligible population (denominator) and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a rate based on all patients in a given practice for whom data are available and who meet the eligible denominator criteria. The specifications listed below are those needed for performance calculation. (Eligible Population) ICD-9 346.0 Migraine with aura 346.00 346.01 346.02 346.03 346.1 Migraine without aura 346.10 346.11 346.12 346.13 346.2 Variants of migraine 346.20 346.21 346.22 ICD-10 G43.109, Migraine with aura, not intractable, without G43.119, Migraine with aura, intractable, without G43.101, Migraine with aura, not intractable, with G43.111, Migraine with aura, intractable, with G43.009 Migraine without aura, not intractable, without G43.019 Migraine without aura, intractable, without G43.001, Migraine without aura, not intractable, with G43.011, Migraine without aura, intractable with G43.809, Other migraine, not intractable without G43.819 Other migraine, intractable, without G43.801, Other migraine, not intractable, 2014. American Academy of Neurology. All Rights Reserved. 66
346.23 346.4 Menstrual Migraine 346.40 346.41 346.42 346.43 346.5 Persistent Migraine 346.50 346.51 346.52 346.53 346.6 Persistent Migraine aura with cerebral infarction 346.60 346.61 346.62 346.63 346.7 Chronic migraine without aura 346.70 346.71 346.72 346.73 346.8 Other forms of migraine 346.80 346.81 346.82 with G43.811, Other migraine, intractable, with G43.829 Menstrual migraine not intractable, without status migrainous G43.839 Menstrual migraine intractable without G43.821 Menstrual migraine not intractable with G43.831 Menstrual migraine intractable with G43.509 Persistent migraine aura without cerebral infarction, not intractable, without G43.519 Persistent migraine aura without cerebral infarction intractable without G43.501 Persistent migraine aura without cerebral infarction not intractable with G43.511 Persistent migraine aura without cerebral infarction intractable with G43.609 Persistent migraine aura with cerebral infarction, not intractable, without G43.619 Persistent migraine aura with cerebral infarction, intractable, without G43.601 Persistent migraine aura with cerebral infarction, not intractable with G43.611 Persistent migraine aura with cerebral infarction, intractable, with status migrainosus G43.709 Chronic migraine without aura, not intractable, without G43.719 Chronic migraine without aura, intractable, without G43.701 Chronic migraine without aura, not intractable, with G43.711 Chronic migraine without aura, intractable, with G43.809 Other migraine, not intractable, without G43.819 Other migraine intractable without G43.801 Other migraine not intractable with 2014. American Academy of Neurology. All Rights Reserved. 67
346.83 G43.811 Other migraine intractable with status migrainosus 346.9 Migraine unspecified 346.90 346.91 346.92 346.93 G43.909 Migraine unspecified not intractable without G43.919 Migraine unspecified intractable without G43.901 Migraine unspecified not intractable with G43.911 Migraine unspecified intractable with Cervicogenic headache 339.89 cervicogenic headache G44.89 Cervicogenic headache AND CPT Evaluation and Management Service Codes: Outpatient: 99201-5, (Office or other outpatient visit-new Patient); 99211-5 (Office or other outpatient visit-established Patient); 99241-5 (Office or Other Outpatient Consultation-New or Established Patient); 2014. American Academy of Neurology. All Rights Reserved. 68